In the provision of medical services, one way of describing the process by which medical services are provided is through the concept of a clinical pathway. Any given treatment regime or clinical procedure, may be easily described as a related series of care events. Each care event has a some relation to the preceding and/or following care events that is logical and reasonable. For example, take a simple procedure such as suturing a wound. The task of suturing a wound can be described as a series of care events: 1) examination of the wound; 2) cleansing of the wound; 3) anesthesia; 4) suturing of the wound; and 5) dressing the sutured wound. Thus, each of these related care events, make up a clinical pathway for the procedure of suturing a wound. To a person familiar with the medical environment, it will be apparent that each of the care events could be broken down into a more detailed series of sub-care events, thus, the concept of the clinical pathway is scaleable; that is, any given care event may be made of a series of care events and can therefore be described as a clinical pathway.
The concept of the clinical pathway may also be expanded to more involved procedures. For example, a patient might go to her doctor complaining of particular symptoms. The doctor might then make an examination, or order tests. Based upon the result of the examination and/or tests, the doctor would make a diagnosis and prescribe a treatment regime. Assume that the treatment regime included a surgical procedure to be performed in a hospital, as well as follow-up care. In this case, the clinical pathway might look like: 1) patient induction (basic administration getting the patient into the doctor's system); 2) examination; 3) testing; 4) diagnosis; 5) prescription of treatment; 6) admission to the hospital; 7) pre-surgical testing; 8) pre-operative preparation; 9) anesthesia; 10) surgery; 11) post-operative recovery; 12) discharge from hospital; 13) follow-up treatment; 14) final discharge. Once again, it is obvious that each care event in the given example might be further broken down into smaller incremental care events and, thus, represent a clinical pathway of its own. For example, the surgery could be broken down into each step associated with the surgery from the initial incision until the incision is closed.
In addition to the fact that each care event represents the provision of some type of medical (or administrative) service, each care event will also require the allocation of some type of resources in order to be performed. These resources may be in the form of labor (doctor, nurse, technician, data clerk, etc.), equipment (x-ray machine, respirator, vital signs monitors, etc.), or supplies (sponges, surgical instruments, drapes, x-ray film, sutures, medications, etc.). Thus, for each care event it is possible to identify the allocation of resources necessary for completion of the care event. For example, for the examination step described in the second example, the allocation of resources could be: 15 minutes of doctor's time, use of a specimen collector, use of a specimen container, and the use of a blood collection kit. Likewise, the testing step might include the use of an imaging device (such as an x-ray or MRI machine), 30 minutes of technicians time, use of x-ray film, use of an x-ray developer and associated chemical supplies, and 15 minutes of a radiologist's time to interpret the images.
By describing events in the context of a procedural pathway, a framework is provided which allows for the systematic classification of the steps necessary to treat a particular patient as well as identifying the resource allocation necessary to properly complete the clinical pathway. In the current healthcare environment of cost control and containment, the use of the clinical pathway framework provides an effective and efficient method for characterizing and analyzing the provision of health-care services in the clinical environment.
One important consideration in the provision of health-care is the allocation, utilization and consumption of resources such as labor, durable equipment, reusable supplies and disposable supplies. The provision of medical supplies for use in the clinical environment, most particularly in the hospital environment, has evolved through over time as the nature of health care provision and, importantly, cost reimbursement, has changed. For example, in the past, the most common way for supplies to be obtained by hospitals was for a central supply service to order the individual supplies anticipated to be needed for a given time period. These supplies would be maintained in a supply room until needed for a given procedure. Once a procedure had been scheduled, a pick list (a list of supplies) would be generated based on the procedure and the doctor performing the procedure. A hospital employee would then use the pick list to withdraw the desired items from inventory and place them in the operating room where the procedure would take place. After the procedure was completed, unused supplies would be returned to inventory, a list of used supplies provided to the billing department, and the used supplies disposed of or re-sterilized. However, this system was costly and inefficient.
For example, a relatively large inventory of supplies had to be maintained, particularly for standard items such as drapes, sponges, sutures, clamps, etc., which could be used in a large variety of procedures. The inventory of such items had to be large in order to insure that sufficient quantities were on hand for every procedure. Furthermore, the act of picking items for surgery and, later, restocking unused items, was onerous and expensive since relatively highly skilled labor was utilized to insure that the proper items were collected and that the restocked items were placed in the proper location. In particular, the restocking of unused items was a substantial burden on the hospital. Due to the then current mode of reimbursement for supply costs each item pulled from inventory had to be either used (and billed for) or restocked (and not billed for). If an item was not used during the procedure and was billed for anyway, the billing for that product could be considered fraud on the reimburser. Since items were often individually wrapped, the restocking procedure could be very time consuming, particularly where sufficient quantities of items were picked from inventory to cover any situation during surgery (i.e., it would not be uncommon to withdraw 10 clamps from inventory and use only 3 or 4, except in situations where heavy bleeding is encountered, which might necessitate the use of all 10).
This situation led to the development of the procedural pack. Initially, suppliers started noting that certain combinations of supplies were used in almost all surgeries. For example, a series of drapes would almost always be used. Thus, a procedural drape pack was developed which included a collection of the most commonly used drapes in numbers commonly used. These drapes were packaged and sterilized as a unit, so that the use of any portion of the unit constituted use of the entire unit. For example, the pack might contain 5 drapes, but only four might be used during surgery. However, since the package was opened, and sterility was thereby compromised, the entire unit could legitimately be considered used. Although some waste occurred, this system cut out the required re-stocking cost.
Initially, small procedural packs and packs were developed for common events. Incision packs, anesthesia packs, suture kits and a variety of other procedural packs, or supply bundles, were developed. As hospitals grew more used to the concept of procedural packs and packs, the demand for more comprehensive supply bundles increased. The procedural pack or pack ultimately evolved into a large bundle, differentiated by surgical procedure, that included all disposable components for that procedure.
In the era of cost--plus reimbursement, the hospitals had an incentive to use ever growing, comprehensive procedural packs. Use of a large pack, with all possible components present, served to minimize the amount of labor required to pick items from inventory and restock unused item. Additionally, it allowed hospitals to greatly reduce their inventory since such packs could be ordered on an as-needed basis, instead of maintaining a large inventory supplies. However, in order to increase these efficiencies, the packs had to be able to cover any possibility that might reasonably be encountered during the procedure, and often included a large amount of supplies which were not often used in most procedures.
With the advent of cost-containment in the health-care environment, the care providers are required by the reimbursers, to minimize expense and cost wherever possible. Under the tenets of managed care, if a supply is not used during a procedure, then the reimburser is not willing to pay for that supply. This environment leads back toward the concept of having an inventory of supplies which are pulled and then restocked when unused. However, reimbursers do realize that some waste in the use of supplies is justified in order to minimize labor expenses concerned with the pulling and restocking of supplies. Thus, the pressure on suppliers led to the development of "custom procedural packs." These custom packs attempt to be comprehensive, but are tailored to the circumstances to attempt to minimize waste. For example, there is a "parts list" or supply list generated by each doctor for each procedure performed by that doctor in a given hospital. Thus, doctors are able to specify the supplies desired, the quantities desired and, if a preference is felt, the brand and type of the desired supply. Thus, if Doctor A uses more lap sponges than Doctor B, their preference cards will differ. Under the cost-plus reimbursement scenario, a procedural pack would have been developed which just had the maximum number of lap sponges used by any doctor. The extra lap sponges in a pack provided to Doctor B would just be wasted. However, under managed care, a custom procedural pack could be developed for Doctor A and Doctor B which allowed for the differing preferences. Once again, however, the more specialized the custom procedural pack, the more inventory will have to be maintained. Since there is the potential for each doctor to have a different custom procedural pack for each different procedure performed by the doctor, there would be no standardization of packs in inventory and, therefore, a number of each custom procedural packs would be required for each doctor.
In the final analysis, a balance must be met between standardization of procedural packs, which will allow for the greatest savings in inventory, because more standardized packs can be used for more different doctors and procedures, and customization which minimizes the waste developed due to usage differences from doctor to doctor and procedure to procedure. It will be apparent to one skilled in the art that the proper balance of standardization and customization will result in the minimum of cost, by minimizing both waste and inventory. Thus, with proper balancing, both the reimburser will save money, due to decreased waste, and the care provider will save money, due to inventory control.
Custom procedural packs have been present in the medical supply industry almost since the inception of the procedural pack. As a marketing technique, the pack manufacturers were willing to customize packs to gain a competitive advantage over other manufacturers and gain an entree to new accounts. However, recently, the industry has become more sophisticated in developing custom packs and packs with the cooperation of the customers. Initially, custom procedural packs were slight variations of standard packs or packs already offered by the manufacturer. However, with increasing customization demands and ever changing product offerings, a more sophisticated method of developing custom procedural packs was required.
One approach to the problem is described in U.S. application Ser. No. 08/889,948, filed Jul. 10, 1997, entitled Method for the Supply of Medical Supplies to a Health-care Institution Based on a Nested Bill of Materials on a Procedure Level, which is a continuation in part of U.S. Pat. No. 5,682,728, issued Nov. 4, 1997, entitled, Method for the Supply of Medical Supplies to a Health-care Institution Based on a Nested Bill of Materials on a Procedure Level, the entire specification of which is hereby incorporated by reference. As may be seen in this application, using the clinical pathway approach described above, each medical procedure may be described as a series of procedures to be performed in a specified order. Thus, at each step in the clinical pathway, the supplies needed to complete that step can be expressed as a supply bundle (or bundles) which will be utilized during that step. Thus, using the clinical pathway model, a nested bill of materials for a given clinical pathway, at the procedural level, may be generated to develop a supply list for the contents of a custom procedural pack. The clinical pathway model allows for an easier approach to analyzing the supplies which will be needed at each step, since it provides a break-down of each phase of a medical procedure.
The procedure for developing the types of custom procedural packs described herein will include some starting point based upon historical usage. For example, say that the hospital already has a standard procedural pack for a laparoscopic gall bladder surgery. The supply list for this standard procedural pack could provide the template for developing the custom procedural packs for that hospital. After first organizing the template supply list into a nested bill of materials as described in the above referenced application and patent, the template would be modified by each doctor's preference card to develop a custom nested bill of materials for each doctor who performs that procedure in the hospital. The step of organizing this initial bill of materials for each doctor will require some judgment in order that minor differences in supply usage are minimized (i.e., if one doctor uses 2 units of a low cost item, and another doctor uses 3 units of the same item, it is probably cheaper to standardized both bills of materials to 3 units; conversely, if the item is a high cost item, it is best to differentiate the bills of materials). The result is that a bill of materials for a procedural pack is developed for each doctor for each procedure.
With a bill of materials developed for each procedural pack for each procedure, the various suppliers of the products can then develop supply bundles for each step set out in the clinical pathway. Typically, not all of the supplies will be provided by a single supplier or manufacturer, so that, as described in the above-referenced application and patent multiple supply sources will develop supply bundles for inclusion into the procedural pack for a given customer. As described in that application, a container may be shipped to each source of supplies and the supplies provided by that source can be added to the container, thus reducing the time and shipping costs associated with collecting and shipping various components to a single assembly location. In operation, the initial source of the container would develop a work order based on the nested bill of materials which each supplier would use to add the appropriate supply bundles to the container. Alternatively, each supplier could ship its supply bundle to a centralized assembly location for assembly of the container and shipment to the ultimate customer. This supply paradigm provides the customer and the suppliers with a framework within which the suppliers can respond very rapidly to an order by the hospital for a custom procedural pack. Thus, even though there exists the possibility that a large number of different packs may be developed for each hospital, the hospital need not maintain a large inventory of such custom procedural packs since the supply process has been streamlined. With proper implementation of the system, a very small number of custom procedural packs may be kept in inventory by the hospital (maybe one week's worth) which will obviously reduce the inventory costs of the hospital. Similarly, since the parts list, or nested bill of materials for each pack has been analyzed, waste is minimized and efficiency is enhanced.
In this supply paradigm, which has been implemented by the assignee hereof, DeRoyal Industries, Inc., under the trademark and service mark TRACEPAK, an attempt is made at the time of the development of the nested bill of materials for each custom procedural pack to minimize waste while maximizing standardization to ultimately reduce the overall cost to the care provider. However, this initial analysis is not sufficient to insure that the bill of materials remains optimized. For example, doctors are constantly revising their supply usage based upon new surgical techniques. Similarly, manufacturers are constantly updating their products to incorporate new products and developments. Also, prices are constantly changing in the marketplace.
Upon review of the foregoing, there are several areas where intervention is necessary to insure that the process results in the best balance between waste minimization and standardization, in addition to the ultimate requirement that all of the supplies required during a procedure are actually available when the procedure is conducted. First, the clinical pathway must be developed. Second, bills of materials must be developed in the context of the clinical pathway and balanced to account for doctor preferences, standardization and waste minimization. Finally, usage of materials must be tracked in order to insure that the bills of materials currently in use are optimized to continue to minimize waste while maximizing standardization, as well as providing a basis for documenting resource usage during a procedure in order to allow for proper billing of the procedure to the party responsible for paying for the procedure.
An additional element that must be considered in the clinical pathway is not only the optimization of the bill of resources through utilization review and standardization, is the scheduling of the resources so that the proper resource is in the proper location at the proper time. Prior art methods of scheduling resources have been organized around OR scheduling programs such as the OR scheduling program available from DeRoyal Business Systems, LLC, an affiliate of the assignee hereof. This software is typical of OR scheduling software in that it provides a calendaring function for reserving OR's for use by doctors and allows for the scheduling of various related items such as durable medical equipment, etc. Also, some OR scheduling packages provide a database function for maintaining doctor "preference cards," which are lists of specific supplies that a given doctor will require during the surgery.
However, such software, usually marketed as a stand-alone package, does not function under the clinical pathway management and is not integrated with resource management. Thus, information is typically unnecessarily entered multiple times, in multiple locations, on multiple information systems. For example, a bill of materials may be generated for a given medical procedure for use by the supply department of a hospital in order to insure that the needed supplies will be available; separately, the doctor preference card from the OR scheduling package will be used to make sure that the supplied materials matches the doctor's preferences; the availability and provision of labor resources will be handled by a different department with a different information system. Usually, these information systems are not integrated and their use results in a myriad of duplication of data entry, along with substantial opportunities for error. Finally, these information systems do not typically provide a basis for calculating medical procedure costs in an efficient manner, so that cost recovery and cost reductions processes must be done on an ad hoc basis.
Returning to the top level of the clinical pathway analysis, the performance of a medical procedure represented by the clinical pathway requires that all of the necessary resources be brought together at the appropriate time and place, which requires that supplies be accounted for and personnel and other resources be scheduled. Once the procedure has been performed, it is important that resource consumption/utilization be recorded for the purposes of cost recovery and utilization review. Finally, it is important that the information be available for analysis in order to allow the process to be analyzed in order to facilitate more efficient resource utilization and to identify economies which may be realized in the clinical pathway.
To date, no hospital information system provides an integrated package for OR scheduling/preference card management, resource consumption logging/storage and resource utilization analysis/bill of resource standardization. Furthermore, even the most comprehensive hospital information systems are written in monolithic style which either represents a 100% custom application written specifically for the customer, or an off-the-shelf application that does not meet all of the needs of the customer. Neither situation fits the current health-care environment of reform, cost-cutting and change. Monolithic software packages require the review and revision of large blocks of source code and a small change at one point may well affect the functioning of other portions of the code. In large applications, hundreds of thousands, if not millions, of lines of code must be reviewed for every change, even if relatively minor. This state of affairs often results in health-care institutions refusing to adopt cost-saving and efficiency enhancing measures, since the potential benefits are often outweighed by the cost and problems which would be involved in adapting their current information systems to the better processes. Also, since different institutions are different sizes, serve different populations, use different doctors, have different areas of core competency, etc., the one size fits all approach to off-the-shelf information systems often results in some institutions adopting procedures which, while they may work well in some environments, aren't the most efficient for that institution just to enable the use of a given information system. However, such a system is in actuality backwards, the institution should be able to determine the most efficient way to operate and then have an information system which is adaptable, at no great expense, to the needs of the institution.
It is therefore an object of the present invention to provide an integrated information system for use in healthcare institutions for managing, optimizing and analyzing the use of resources within that institution.
It is yet a further object of the present invention to provide an integrated information system for us in healthcare institutions for managing, optimizing and analyzing the use of resources within that institution utilizing a modular, component-ware software structure.
It is yet a further object of the present invention to provide an integrated supply, scheduling, and resource utilization management system for use in the health-care environment.